Client type
*
Adult (18+)
Minor (aged 0-18)
Client name
*
First Name
Last Name
Client Date of Birth
*
Client pronouns
*
Client email address
*
Client phone number
*
(###)
###
####
Guardian's email, enter N/A if 18+
*
Guardian's phone, enter N/A if 18+
*
Reason for seeking therapy and/or nutritional counseling?
*
If you are seeking nutritional counseling and plan to use your insurance, please provide us with a medical or mental health diagnosis as your insurance may require this information. And let us know of your presenting issue for why you're starting work with us.
General availability ~ mark all that apply
*
Will you be using health insurance?
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Yes - BCBS PPO or Choice PPO
Yes - Medicare
Yes - United Healthcare
Yes - Out of network
No - Self pay
Insurance plan name, enter N/A if self pay.
*
Subscriber's first and last name, enter N/A if self pay
*
Subscriber's Date of Birth, enter N/A if self pay
*
Who is the primary subscriber?
*
Patient
Patient's spouse
Patient's parent
Other
If other, please explain
Member ID (please include ALL LETTERS & NUMBERS), enter N/A if self pay
*
Group number (please include ALL LETTERS & NUMBERS), enter N/A if self pay
*
Front of Insurance Card, skip if self pay *
FileField;MaxSize=5120;Multiple;addText=Add_your_Files;
Back of Insurance Card, skip if self pay *
FileField;MaxSize=5120;Multiple;addText=Add_your_Files;
Have you ever been a previous client of Nourishment Works?
*
No
Yes
At this time we have limited in-person availability. Please let us know your preference and we will do our best to accommodate your request.
*
Virtual Telehealth session
In-person session
Either works for me
